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How it works on the day...

The CSA is basically a simulated surgery. There are 13 cases. The GP trainee stays in one room throughout the whole period and different simulated patients come in accompanied by an examiner. Each simulated consultation lasts 10 minutes. There is a 2 minute break between patients where the trainee can take a deep breath, relax, read the notes for the next case and get themselves in a ready-enough state to consult. The cases vary in complexity – some are very straightforward and others have different levels of difficulties – do not think that all of them are going to be very hard. This variety of cases is meant to reflect what happens in the real world and helps pick out those trainees who can handle a varying level of challenge. Those who can are deemed to be ready to become qualified GPs.

All the consultation notes for each case is provided on an tablet device. There’s also a clock in the room which will help the trainee keep an eye on time and help them gauge how well they are doing in this respect. About 3-4 of the cases will involve a clinical examination. You will know whether a case requires an examination or not by simply saying to the patient “I’d like to examine your xxxx”: if you are not required to do an examination, the examiner will provide you with a sheet detailing the examination findings; if an examination is required, the examiner will say and give you nothing.

Throughout the examination, the examiner will not interact with you much. And the examiner will keep a straight face – in other words, they will not give you any indication of how well (or bad) you are doing. As a result, a lot of trainees say that they can’t tell how well they did in each case – so if you feel like this, please remember it is normal. It does not necessarily mean you were bad.

Not all CSA cases will be a face-to-face consultation. One might be a telephone consultation. Another case might be a home visit where you will be escorted out of your room into a designated ‘home visit’ room which will have been dressed up like a bedroom or front lounge.

Also remember that the CSA examiners are all GPs. They are not there to trip you up and they are definitely NOT trying to fail you. If anything, they want you to pass and they would be delighted to give you lots of marks – but they can only do that if you show that you are good enough. I’ve spoken to many trainees who have done the CSA and most of them say it is a really fair exam.

Dr Arora explains a bit more about the CSA in the video below.

Did you know…

Did you know that the CSA is a very expensive exam for the RCGP to run? Imagine all those examiners and simulated patients that need paying for their time and expenses. Then there’s the cost of the training workshops throughout the year to train up the examiners and simulated patients. Let’s not forget the CSA case writers, the development team and of course the administrators. I hope you can see how it is a very difficult examination to coordinate – it takes a lot of time and effort to put together. Can you see why each sitting costs about £1700 per go? So, if you think the RCGP makes a lot of money out the CSA – think again! They don’t.

What's it testing & how is it marked?

A lot of people think that the CSA is mainly testing consulting skills. And they believe that if you are a nice doctor, and that you are nice to the patient and give them all they want that the trainee will succeed and get through. THIS IS NOT TRUE. Yes, the CSA tests communication skills. But the CSA also pays equal importance to testing your history and examination skills (data gathering) and your clinical management of the case.

Here are the 3 domains being tested…..

DATA
GATHERING

history, examination, consulting skills, ICE

Data gathering is where you do your history taking and examination. You will be tested on WHAT questions you ask (i.e. asking the right set of questions). In addition you will be tested on HOW you ask (communication skills) and whether you are methodical, structured and comprehensive.

CLINICAL Mx

diagnosis, NICE guidelines, share options, joint management plan.

Clinical management means synthesising what you’ve got from Data Gathering to form a reasonable working diagnosis. It also means that you know your guidelines (e.g. NICE), share options with patients, and develop a joint management plan with them. Of course, one needs to be mindful of co-morbidity and be flexible in their approach where clinically appropriate.

INTERPERSONAL SKILLS

consulting skills, rapport, respect, professionalism

Interpersonal skills is about you developing rapport with the patient. It also involves showing respect for them, for their point of view and being appreciative of the psycho-social impact of a disease on their life. You should show respect for others (like family members, other health professionals) and maintain a sense of professionalism. Interpersonal skills is more than just being a nice doctor!

You are basically given a mark for each domain. Each area has a maximum of 3 marks. That means each case has a total of 9 marks. There are 13 cases which gives a total of (13 x 9) = 117 marks. You generally need about 72-78 out of the 117 marks to pass – depends on how hard the cases are.

When should I do the exam? And when should I start practising?

Simple – in ST3 only. Not any earlier. You definitely need to have about 10-12 months experience and preparation time in a GP post.

In terms of practising for the CSA…

In the 1st month of a GP ST3 post

Read up about CSA basics – what’s it testing, how it all works, visit the RCGP CSA pages etc.

2nd month

Once you’ve settled into your GP post, gradually start practising some of the consultation micro-skills with real patients. A microskill is a small segment of a consultation skill – like exploring a patient’s ideas or explaining the diagnosis or management plant to them.

Start reading a consultation book – this will help you identify consultation microskills you need to improve. (see section below on micro-skills)Also start doing some COTs and look at these with your trainer. (more on this below too)

With real surgeries, identify clinical areas you find difficult and brush up on these in a gentle way (e.g at the end of surgery or even in real time with patients if you can).

4-5 months BEFORE the exam

5-6 months before the exam – book it !

Book the hotel and train tickets too.

Join a CSA study group. Again, more on this below.

Start practising CSA cases with others. Get those CSA books and start meeting with others and practising at least on a weekly basis. Start doing some real heavy CSA work and practice.

At this stage, you may feel very pressured so remember to take regular breaks and to continue enjoying those nourishing activities in your life. If you find that you are not engaging with your former nourishing activities – you are going to burn yourself out. So make time for them because they will revitalise you and help you learn things in half the time.

Week before the CSA exam

Calm down and take it easy. Let your brain breathe. Do not overload it. The more it can breath and feel relaxed, the better your performance will be in the CSA exam.

Get your CSA exam equipment together.

Prep 1 - start reading a consultation book

Although some people are naturally good at patient-centred consulting and others less so. But the good news is that these skills can be learnt. Yes! Even if you are not good at consulting in a person-centred way, with practice you can learn to be as good as those who are naturally good. Thats where a consultation book can help.

Of course, the key word here is practise! You can’t just read about the skills. You need to have a go at them and practise and play around with your words and phrases until you find ones that work for you. If you’re the type that likes to study – excellent! By all means do so. But please do not forget about PRACTISING. Without practice, you won’t acquire the SKILL. Would you be happy driving with a driver who said to you that he or she has never driven a car before but has read a book that teaches all the skills to do so?

Reading a consultation book or two will

Help you get some of the cores communication skills to consult effectively with patients.

Help you identify consultation micro-skills you need to work on and improve.

The Naked Consultation by Liz Moulton (very much loved by GP trainees because it is easy to read and covers a variety of tricky scenarios).

Prep 2 - video yourself & start doing some COTs with your trainer

COT is short for Consultation Observation Tool. In other words – VIDEO WORK! Yes, videoing some of your patient consultations so that you can analyse your consultation style, communication skills and clinical approach with the patient. Many people feel apprehensive about showing themselves on video. This is a NORMAL REACTION – we all feel like that, even us educators!

But trust me when I say it is one of the most amazing ways of looking at yourself and seeing exactly where you can improve to become an even better doctor than you already are. Also trust me when I say that your trainer will be sensitive when reviewing your video with you. After a few sessions, you will no longer feel apprehensive about showing your consultation videos – in fact, you will want to! Reviewing your consultation videos will really help you pass the CSA. If you want to pass effortlessly, then pluck up the courage and overcome your fear and start doing some videos.

And of course, don’t just video yourself for COTs. Video your real consultations for yourself and see how you talk and behave. You’ll notice things about you that you will want to change. You don’t always need a Trainer or TPD to advise you. You have it within yourself to reflect and advise yourself too.

One last thing – if you’re in a CSA group – think about videoing the role-play interactions there too. Watch the video with other group members, yourself alone, and with your trainer or another qualified GP.

Why do I say video is key to CSA success? The thing is we often don’t realise we are doing certain things because we cannot watch ourselves. We don’t have a third eye. However, the video can be the thing you need to provide that third self-reflecting eye. See video as a window of CSA opportunity!

Prep 3 - Join or Make a CSA group

You have to get out there and practise – it’s the best way of achieving the level communication, clinical and interpersonal skills required to pass the CSA. The number of GP trainees I see that try to memorise stuff from CSA books is beyond belief – it’s crazy to rely heavily on books because what is being tested is not just what you know but what you say, how you say it and how you perform and interact with the patient. Good ‘performance’ can only be gained through regular practise, not through reading a CSA book!

Remember what I asked you earlier? Would you be happy driving with a driver who says that they’ve never really driven a car properly but they have memorised a book that teaches all driving skills?

Prep 4 - In the beginning... focus on the story, not the timer

You have 10 minutes per case in the CSA. But if you are just starting off, you should not worry about that. So, if you’re starting out on your CSA practice, forget having a timer (by the way, you should be start preparing for you CSA at least 6 months before the exam date). At this stage it is important that you focus on

developing your consultation framework

learning how to follow the story (the patient’s narrative)

taking a good enough history and examination

improving your explanations and

learning how to formulate a joint management plan.

Later on, say 3 months before the exam, your consultation skills should be good enough. It is at this 3-month-before-the-CSA-date that you can start getting the timer out and trying to do it all in 10 minutes. And practice twice a week.

Prep 5 - Other things

Attend Mock CSA sessions

All GP training schemes up and down the country run s either at HDR or externally.

In fact, some Deaneries put on special mock CSAs throughout the year (like Yorkshire & the Humber do).

Make sure you don’t miss out on these invaluable practise opportunities.

There are DVD resources you can buy too. Do a search on Amazon or something.

Practise in a variety of ways with your GP Trainer

Ask your trainer to do some role playing CSA sessions with you. Perhaps one half of the weekly tutorial can be devoted to this?

Also ask them to look at your consultation videos not just via the COT proforma but via the CSA proforma too. Ask them to grade according to the three CSA domains: 1. Data Gathering 2. Clinical Management 3. Interpersonal Skills. Ask them to give you a score out of 3 for each one. 0=really bad. 1= fail. 2= pass. 3 = excellent

During Sit and Swap surgeries (ask your trainer if you don’t know what these are) – ask your trainer if they can pick a couple of patients to asses CSA style.

Most important: SEE REAL PATIENTS IN REAL SURGERIES

The biggest training session you have in your daily working life is normal surgery consultations with real patients.

Many GP trainees will book weeks off to ‘study’ for the CSA – when actually, it’s the practise that is important. And what better way to practice your consultation and clinical skills than with real patients who present with a wide variety of things.

If you get stuck with a patient – if it’s a clinical thing – look it up. If it’s a consultation skills thing – talk to your trainer.

Reflect on

your clinical knowledge

you communication style and behaviour and the way you say things

your attitude and behaviour

This is a much better way of learning and improving your yourself than books – because it is all about how you perform at the end of the day rather than what is in your head! If you can’t get what’s in your head effectively out in the consultation then it isn’t really any good is it?

The other great thing about seeing real patients in real surgeries is that the type of clinical things and the types of issues you will encounter will be similar to what pops up in the CSA exam. If you have seen lots and lots of real patients in real surgeries, then the cases that come up in the actual CSA exam should not surprise you. Equally, if you haven’t seen lots and lots of patients in real GP surgeries, the things that come up in CSA will not be familiar to you and you will struggle.

Sit in with your GP trainer and observe him/her – this will open your eyes to alternative approaches, wordings and skills.

Sit in with other health professionals, like the nurses, and observe how they do things like asthma reviews.

Final top tip – VIDEO YOURSELF

VIDEO YOURSELF – not just for COTs.

Video your own surgeries (with consent of course). And then watch them by yourself – you don’t always have to use a trainer or TPD. You’re an adult learner and you should be able to educate yourself.

Video the role plays in your CSA study group – suggest it to them. You/They might not like it at first, but it is an incredibly powerful tool that can help you pass. By the end, you will love video work (or something closer towards love!).

Like I said before, video provides that vital third external diagnostic eye that you can turn towards and reflect on yourself. It makes you aware of things you say and do which you would not be aware of otherwise. Sometimes what we think we have said or behaved is far from what actually was said or done. Video is the thing that will open your eyes. So video your surgeries and video your role plays in the CSA study groups. Watch some together with your trainer, TPD and trainees and watch some on your own.

Top Tips from Others

Please leave a comment below if you have any words of wisdom to help others or if you have any questions you wish to ask…

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